Employment-related Injuries or Illness

There are generally three types of legal remedies available to members who sustain employment-related injuries or illnesses:

• Workers’ Compensation under state law – Workers’ Compensation under state law is a legal remedy whereby an employee who is injured within the course and scope of employment is usually entitled to certain benefits regardless of whether anyone was at fault.

• Longshore & Harbor Workers’ Compensation Act (LHWCA) - The LHWCA is a federal law that provides for the payment of medical care to employees who suffer “on the job” injuries that occur on the navigable waters of the United States or in adjoining areas used in loading, unloading, repairing or building certain vessels, regardless of whether anyone was at fault.

• Jones Act – The Jones Act is a federal law that provides protection only to “seamen” who are injured while working on a vessel.

Please understand that we do not make any coverage determinations as to which legal remedy would apply to a member’s injury.

We understand that it can be very difficult to determine which one of these legal remedies may cover a particular injury or illness; however, your patients may have medical benefits available to them under their Blue Cross contract. All claims for covered services, including those claims for which a third party may be liable, must be filed directly to Blue Cross. Please understand that services for injuries and illnesses that arise under the Jones Act, like any other covered services that do not fall under any workers’ compensation guideline, are not considered contractual exclusions, and therefore, must be filed with Blue Cross. Although services that fall under a workers’ compensation guideline are, in most circumstances, typically excluded under the terms of the member contracts/certificate of coverage, we strongly encourage our providers to file claims for these services with us. If the service is determined not to be covered by workers’ compensation or the particular contract does not exclude these types of services, you risk any future consideration by failing to meet administrative filing requirements. The current administrative claims process may deny an initial claim for employment related injuries however, please contact Customer Service so that we can work with your office to apply the appropriate member benefits.

Coordination of benefits does not apply in any of these scenarios.